Question: An established patient was in an automobile accident in which he collided with an object in the road. He came to see the internist complaining of jaw pain. The internist performed a level-four E/M service, diagnosed abnormal jaw closure and referred the patient to a surgeon. What ICD-9 codes should I report for this encounter?
Alabama Subscriber
Answer: You'll need a pair of diagnosis codes here: one regular ICD-9 code and one E code. On the claim, report the following:
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity) for the E/M.
• 524.51 (Abnormal jaw closure) linked to 99214 to represent the patient's condition.
• E815.0 (Other motor vehicle traffic accident involving collision on the highway; driver of motor vehicle other than motorcycle) linked to 99214 to represent the cause of the patient's condition.
